Prior authorization has been a bone of contention between payers and providers for some time now. Payers argue that it helps avoid unnecessary care and reduces costs, while providers say it creates administrative burden and delays care.
So what if it all went away?
This was a question that Chris Severn, CEO of Turquoise Health, a price transparency company, asked of Don Antonucci, CEO of Providence Health Plan at a fireside chat in Las Vegas. The chat was part of an intimate networking event — Tête-à-tête Health — that MedCity News hosts at healthcare conferences. These conversations feature executives discussing how healthcare can be transformed to make the system work equitably and affordably for all. The event in Las Vegas was sponsored by Cohere Health, a company that leverages AI to smoothen the prior auth process.
Antonucci responded it would be “pretty scary” for payers if prior authorization simply disappeared.
“Prior auth is not just about cost, it’s also about, is somebody getting the right care that they actually need?” he said. “There are some real clinical aspects to prior auth. I think the idea over time would be that that could really start to go away or go away for the majority. [This] is happening more and more now, systems between payers and providers talking to each other so we can get out of the war on prior auth, and get … back to that focus. Is this the right care, the most effective [care]?”
Indeed, several payers have been cutting down on prior authorization requirements, including UnitedHealthcare and Cigna Healthcare.
Antonucci agreed, however, that the prior authorization battle has been “antagonistic.” A big reason for this is that providers are hitting a breaking point financially, he said. He did note that Providence Health Plan is in a unique position. The Portland, Oregon-based insurer is part of the nonprofit healthcare system Providence and has about 660,000 members.
“Even though 30% of the utilization of our health plan goes through Providence, we have other partners outside of it. We are positioned a little bit stronger because we do understand the pressures,” he said. “At the end of the day, what providers would say is that they’re looking to be paid fairly for the services they provide. A lot of what we do, because we also have prior authorization, is making sure that we’re listening, really communicating with our providers any changes that we’re making. We’re making sure we’re doing it eyes wide open, and that has been really beneficial for us with not just Providence, but also outside of Providence.”
Antonucci added that with AI, the healthcare industry could get to a point where prior authorization largely goes away, but we’re not there yet. That said, AI is currently being used to speed up the prior authorization process. At Providence Health Plan, a lot of the AI tools it uses start with Providence’s delivery system. Antonucci gave the example of a solution called Xsolis, which started on the delivery system side to help with coding and reduce the length of stay.
“What we’ve done on the health plan side is we’ve reviewed Xsolis, because they also have a health payer application to it, and found that actually the coding for inpatient stays is really accurate,” he said. “It’s really well done, and it’s passing all of our prior auth. Because a health plan also does things like concurrent review it’s now on us to look at that and go, ‘From an administrative efficiency standpoint as a health plan, do we need people doing this concurrent review in these areas when, at the end of the day, this is all coming through and going through the system appropriately?’”
But there are also reports of AI being used to deny prior authorization requests, leading to calls for greater scrutiny of the practice. For example, UnitedHealthcare, Humana and CVS have all received criticism for using AI to deny requests for post-acute care.
Antonucci said there are five categories he considers when he looks at AI: if it improves affordability, if it improves access, if it improves quality, if it improves the experience for patients and providers, and if it improves health equity.
“We’ve got to really start to break through this — because it’s a huge problem, we know that the prior auth denials have gone up quite a bit — and come to a place where, what’s the right care? Put yourself in the position because we all go through the healthcare system. What would you want for yourself, a family member, a friend?” he urged. “What we want at the end of the day is the right care in the most affordable manner that’s high quality. I think that’s the dialogue everybody has to get back to because right now, it’s broken and all you’re doing is disenfranchising yourself from consumers, members, providers.”
In addition, there have been calls for a national policy when it comes to prior authorization to make the practice more uniform, including from the American Medical Association. Antonucci said he sees a lot of pros to this.
“Why can’t we come to a standard that everybody would agree on?” he said. “Because I think part of the problem is different payers and different providers have different ways that they’re looking at things and the complexity, and therefore, the fragmentation it causes is significant … I think getting to some type of a common standard makes a lot of sense.”
In short, while prior authorization may not be going away any time soon, there is one thing payers and providers seem to agree on: the practice is in need of major improvement.
The full interview can be accessed here.
Photo: Providence Health Plan
